Recovery of Cognitive Functioning in Alcoholics The Relationship to Treatment

ing (i.e., ascertaining the principles or rules that govern a particular task), and shifting of sets (i.e., recognizing the need for using new rules when the previous rules no longer apply) were associated with frontal lobe damage caused by alco­ hol consumption or related factors. Some MARK S. GOLDMAN, PH.D., is Distinguished Research Professor, director of the Alcohol and Substance Use Research Institute, and director of training in clinical psychology, Department of Psychology, University of South Florida, Tampa, Florida. Portions of this work were supported by National Institute on Alcohol Abuse and Alcoholism grants R01AA06911 and R37AA08333. ALCOHOL HEALTH & RESEARCH WORLD 148 Recovery of Cognitive Functioning visuospatial impairments were connected with a wasting away (i.e., atrophy) of the frontal and/or right hemisphere. In recent years, however, investigators have used more sophisticated brain imaging and cerebral blood flow techniques and found similar neuroanatomical damage in all alcoholics, including those whose deficits are detectable only on sensitive behav­ ioral tests. Thus, differences in cognitive capacity among alcoholics cannot be attributed exclusively to differences in their neurophysiology. How similar forms of damage to the nervous system can result in differing behavioral consequences, including cog­ nitive deficits, in different alcoholics remains unclear. The behavioral changes that researchers observe may result from the general effects of alcohol­related toxicity and other factors (e.g., head injury, liver damage, psychiatric factors, or neurochemical abnormalities) com­ bined with individual differences, such as age and drinking history (Bowden 1990; National Institute on Alcohol Abuse and Alcoholism 1993). Some researchers also have suggested that a portion of the im­ pairments are present in people with a family history of alcoholism even before they begin consuming alcohol (the accu­ mulated evidence for preexisting dysfunc­ tion has been mixed, however; see Drake et al. 1995). Alcohol researchers do not know whether cognitive impairments impede alcoholism treatment. Can a cognitively impaired alcoholic readily absorb all the information that is usually imparted during treatment? Do these deficits make the necessary adjustments and adaptations to a “dry” (i.e., nondrinking) way of life more difficult? If so, can anything be done to help the alcoholic recover from these deficits? This article discusses the partial answers to these questions, first reviewing the course of recovery from alcohol­related deficits, then considering how these deficits may affect treatment outcomes. It concludes by reviewing research on ways to improve treatment outcome by facilitat­ ing cognitive recovery. THE NATURE OF THE DEFICITS AND HOW THEY ARE DETERMINED Test findings from a wide group of stud­ ies show that alcoholics are remarkably free of impairment of general intelligence. Their cognitive deficits are more consis­ tently revealed using specific tests of abstract reasoning and visual perception. In addition, alcoholics have not consis­ tently shown learning and memory deficits despite the fact that more severe versions of these impairments are symptoms of Wernicke­Korsakoff syndrome (see Parsons et al. 1987). These descriptions of alcohol­induced deficits derive primarily from the re­ searchers’ intuitive analyses of what the tests seem to measure, such as abstracting ability or memory. Some investigators use more sophisticated strategies based on cognitive psychology to better understand the nature of the cognitive dysfunctions. Alcoholics

ul recovery depends on their regaining cognitive functioning. Although their cognitive deficits often are subtle and improve with a period of abstinence from alcohol, they can hamper the effectiveness of treatment programs. If patients cannot comprehend the information imparted during therapy, they may not be able to use treatment strategies successfully in "real world" challenges. Cognitive recovery can be enhanced using strategies such as repeated mental exercises. Adding such practice to treatment regimens could improve some alcoholics' chances of recovering successfully. KEY WORDS: AOD impairment; cognitive process; treatment program; treatment method; treatment outcome; AODD (alcohol and other drug use disorders) recovery

A quick review of this issue of Alcohol Health & Research World reveals the impact of chronic excessive alcohol use on cognitive functioning.The most severe impairments are the profound memory dysfunction caused by Wernicke Korsakoff syndrome (for a definition of this syndrome, see the glossary, pp.[136][137] or the more global intellect al deterioration (including memory impair ment) of alcoholic dementia (i.e., general loss of memory functioning, judgment, and abstract thinking).Even among peo ple admitted to alcoholism treatment facilities 1 who show no dramatic cogni 1 In general, the patients described in this article as having been admitted to alcoholism treatment facili ties meet the criteria for alcohol dependence listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

tive impairment, between 75 and 100 percent of the cases (depending on the samples and measures used) perform below normal for their age group on sensitive tests of cognitive functioning (McCrady and Smith 1986).

Until recently, researchers often have attributed the many levels and types of cognitive deficits seen among alcoholics to differing forms of alcoholrelated dam age to the drinkers' neuroanatomy (i.e., the brain's various parts) and neurophysi ology (i.e., the functions of these parts).Researchers considered such differences in impairment to be responsible for any performance discrepancies observed among alcoholics.In addition, researchers attributed Wern ckeKorsakoff amnesia to thiamine deficiency and to the lesions accompanying this syndrome in a variety of brain structures, such as the dienceph alon, mammillary bodies, and basal fore brain, which are associated with memory functions (for definitions and further descriptions, see the diagram of the brain on p. 137).Deficits in problemsolving, abstracting (i.e., ascertaining the principles or rules that govern a particular task), and shifting of sets (i.e., recognizing the need for using new rules when the previous rules no longer apply) were associated with frontal lobe damage caused by alco hol consumption or related factors.Some visuospatial impairments were connected with a wasting away (i.e., atrophy) of the frontal and/or right hemisphere.In recent years, however, investigators have used mo e sophisticated brain imaging and cerebral blood flow techniques and found similar neuroanatomical damage in all alcoholics, including those whose deficits are detectable only on sensitive behav ioral tests.Thus, differences in cognitive capacity among alcoholics cannot be attributed exclusively to differences in their neurophysiology.

How similar forms of damage to the nervous system can result in differing behavioral consequences, including cog nitive deficits, in different alcoholics remains unclear.The behavioral changes that researchers observe may result from the general effects of alcoholrelated toxicity and other factors (e.g., head injury, liver damage, psychiatric factors, or neurochemical abnorma

ties) com bined with individual differences, such as ag
and drinking history (Bowden 1990; National Institute on Alcohol Abuse and Alcoholism 1993).Some researchers also have suggested that a portion of the im pairments are present in people with a family history of alcoholism even before they begin consuming alcohol (the accu mulated evidence for preexisting dysfunc tion has been mixed, however; see Drake et al. 1995).

Alcohol researchers do not know whether cognitive impairments impede alcoholism treatment.Can a cognitively impaired alcoholic readily absorb all the information that is usually imparted during treatment?Do these deficits make the necessary adjustments and adaptations to a "dry" (i.e., nondrinking) way of life more difficult?If so, can anything be done to help the alcoholic recover from these deficits?This article d scusses the partial answers to these questions, first reviewing the course of recovery from alcoholrelated defic ts, then considering how these deficits may affect treatment outcomes.It concludes by reviewing research on ways to improve treatment outcome by facilitat ing cognitive recovery.


THE NATURE OF THE DEFICITS AND HOW THEY ARE DETERMINED

Test findings from a wide group of stud ies show that alcoholics are remarkably free of impairment of general intelligence.Their cognitive deficits are more consis tently revealed using specific tests of abstract reasoning and visual perception.In addition, alcoholics have not consis tently shown learning and memory deficits despite the fact that more severe versions of these impairments are symptoms of WernickeKor akoff syndrome (see Parsons et al. 1987).

These descriptions of alcoholinduced deficits derive primarily from the re searchers' intuitive analyses of what the tests seem to measure, such as abstracting ability or memory.Some investigators use more sophisticated strategies based on cognitive psychology to better understand the nature of the cognitive dysfunctions.


Alcoholics may be deficient in exactly those cognitive capabilities

they need the most to recover successfully.

For example, Parsons (1987) and co workers noticed that alcoholics appear to change a strategy (that may be correct) before it has been sufficiently tested or to continue using ineffective approaches even after it is obvious that they are inadequate.On difficult verbal learning tasks, Butters and Granholm (1987) have suggested that cognitive deficits stem from the inadequate encoding strategies alcoholics use when storing information rather than from a specific inability to learn or remember.In other words, correct information may be placed in a file drawer, but an inadequate label on the file might make retrieval of this information difficult.

Cognitive psychology's techniques thus attempt to uncover impairments in general cognitive processes that may affect many other brain functions.Statis tical research supports the possibility that the more specific deficits in abstracting ability, visuoperception, learning, and memory may be caused by more general and pervasive informationprocessing deficits.Studies indicate that a single underlying process may be associated with most, if not all, the observed deficits on specific tests.Goldman (1987Goldman ( , 1990) ) has suggested that the tests most sensitive to alcohol related cognitive dysfunction have several characteristics in common.They all pre sent stimulus ma

rial that the patient h
s not previously experienced.They require that multiple kinds of information be integrated (e.g., learning to connect a name with a face).And, in most cases, they require that the information be processed rapidly.These challenges require a process traditionally called "attention"; the more recently used term is "controlled."(In fact, a distinguishing characteristic of Wernicke Korsakoff syndrome is impaired controlled memory processes, whereas implicit memory-using remembered information or a newly learned skill without being aware of when or how it was learnedremains relatively intact.For further dis cussion, see the article by Ingle and Weingartner, The capacity to deal with new situa tions that demand the processing of multi ple sources of information underlies humans' ability to adapt to changing cir cumstances.Recovering alcoholics require such adaptability to change from a lifestyle th

includes continual drinking t
one that involves no drinking.Hence, alcoholics may be deficient in exactly those cognitive capabilities they need the most to recover successfully from alcoholism.


TIMEDEPENDENT RECOVERY

When alcoholics cease continual heavy drinking (e.g., as a result of admission to detoxification programs), they typically experience a period of acute withdrawal that may last a few days.During this time, they feel ill and frequently show poor performance on most cognitive tests, probably as much a result of a general sense of malaise as any other factor.It is not surprising, therefore, that they im prove on these tests after the acute with drawal phase.Beyond this relatively brief p

iod, however, real improvement may be ob
erved as time passes.The rate of improvement and the ultimate level of functioning the alcoholic reaches vary with the type of cognitive processing involved in completing a task and with the age of the alcoholic.Sometimes com plete recovery of cognitive functioning can take weeks, or even months or years.In some instances, the alcoholic never completely recovers.


Determining Recovery Patterns

To see how alcoholics' performances change over time after they cease drink ing, it is necessary to measure their per formance on at least two occasions over a specific length of time.Recovery may not progress at a steady pace, so it is best to measure performance on more than two occasions.However, people improve their performance of most behaviors after they practice those behaviors.2Therefore, if an alcoholic improves after repeatedly per forming a particular task, the improve ment may be the result of either true (generalized) cognitive recovery over time or only increased familiarity and practice with the specific instrument used to measure the targeted behavior.


Controlling for the Effects of Practice

Two general approaches have been used to separate recovery from the effects of practice.In one case, each matched group of alcoholics is tested for the first time at different time lags after stopping drink ing, followed by repeat testings also at different times.For example, group one may be tested at weeks 1, 2, and 3 after drinking has stopped, whereas group two m

be tested at weeks 2, 3, and 4.Thi
way, the effects of practice on the tests can be separated from recovery that oc curs over time.If at the first test, group two performs better than group then timedependent recovery is evident.Repeat testings are necessary to ensure that differences between the supposedly matched groups are not the result of unintended discrepancies between the groups (e.g., differences in premorbid intelligence).In the other approach, non alcoholics (usually matched with the alcoholics in education and sociodemo graphic status) are given the same series of tests as the alcoholics to determine what improvement on the tests would be if only practice (and no timedependent recovery) was occurring.The difference in the rate of improvement between the alcoholics and the nonalcoholics is then an indication of the "true" recovery of cognitive functioning.


Patterns of TimeDependent Recovery

When these methodological issues are taken into account and the recovery litera ture is considered, the following patterns of timedependent cognitive recovery emerge (see Goldman 1987Goldman , 1990)).F rst, some cognitive capacities seem relatively unim paired, even early in detoxification, as long as the general malaise of the first few days of abstinence is past.Gross IQ, as meas ured primarily by verbal tests that draw upon prior knowledge, falls into this cate gory.This means, for example, that the vocabulary levels of very recently detoxi fied alcoholics are about the same as they were prior to and after recovery from the acute alcoholic episode that brought them into detoxification.In contrast, any task that requires processing new information, abstracting, or problemsolving, whether verbal or visuoperceptual, still is impaired during the first week or two after drinking ceases.Some sensorimotor functions (e.g., sensitivity to touch) also may be deficient during this period.Other factors, such as age and drinking history, also affect time dependent recovery.

Age. Two to 3 w eks after alcoholics stop drinking, they show considerable recov ery in most verbal processing cognitive functions; these areas may even return to normal functioning levels.At this point, however, the recovery paths of alcoholic subgroups diverge, based primarily on their age.Younger alcoholics (those under age 40) show substantial recovery of all cognitive functions; only the most de manding tests detect residual deficits.For older alcoholics, the picture differs.Although their performance on cognitive tests may continue to improve, deficits can be observed on visuoperceptual and problemsolving tasks for much longer periods of time, even as long as many months or years.In certain studies exam ining deficits in shortterm memory, visuospatial functioning, and attention among older alcoholics, problems have been identified even after 5 years (Brandt et al. 1983).

Drinking History.Most studies have not found that an alcoholic's drinking history relat s significantly to the speed or extent of recovery.Alcoholics with more years of heavy or problem drinking are not more likely to have more lasting impairment than are those with fewer years.This finding is counterintuitive, and the reasons for it are not entirely clear.The brains of people with shorter drinking histories may be more resilient physically or may better carry out neurophysiological adjustments.Or, up to a certain number of drinking years, alcoholics may be ab

to learn to compensate for u
derlying neurological damage to produce unimpaired behavior (e.g., by performing a task a different way).Perhaps a dysfunctional performance only appears after excessive drinking has gone on for a certain length of time, pro ducing a threshold above which cognitive impairments become observable.Or it may be that some asyetundetermined process is at work.

It is clear, however, that a return to alcohol use, even at reduced levels, after some period of sobriety sets back the recovery process regardless of drinking history.Very recent findings further indicate that the effect of drinking re sumption may be more debilitating for alcoholics who also have family histories of alcoholism, although such alcoholics apparently recover just as well as alco holics without such histories if they main tain abstinence (Drake et al. 1995).


EXPERIENCEDEPENDENT RECOVERY

In a series of studies performed over the last 20 years, Goldman (1990) found that cognitive recovery does not result only from some intrinsic neurophysiological healing process but can be influenced by environme tal factors as well.These environmental factors may be likened to physical exercise, but in this case, the "exercise" involves cognitive stimulation.Recovery seems to be accelerated if newly abstinent subjects are asked to "use their heads" at a level that is equal to, or slightly beyond, their current level of functioning.This experiencedependent recovery may happen spontaneously because of naturally occurring events, as when a job requires that a task be performed repeatedly.Alter natively, recovery can be facilitated by planned cognitive activities, such as re peating mental exercises, similar to the use of physical therapy to r

over after a sports injury.In a loose sense, the cogni tive "sw
tchboard" of the alcoholic appears impaired but apparently can be stimulated to more efficient activity by the repetition of appropriate cognitive demands.

Experiencedependent recovery is by no means unique to alcoholism research.Inducing recovery from brain damage by manipulating environmental variables has been seen before in both animal and human research (see Rose and Johnson 1992).Evidence exists now that such recovery is not only a consequence of the subject's adjusting behavior to learn a new method of performing a task.Indeed, studies using a variety of designs to ex amine the effects of environmental changes on neurological functioning have found performance enhancement coupled with actual changes in the nervous system (for further information, see Rose and Johnson 1992).


ExperienceDependent Techniques for Inducing Cognitive Recovery

Practice.The basic strategy for influencing an cognitive recovery has been to repeatedly administer tests that demon strate the subject's impairment.This pr ce dure is nothing more than practice, discussed earlier as a possible experimental confound in timedependent recovery studies.Reexamined in this new context, however, practice does more than facilitate trivial performance improvement on a specific test.If a particular cognitive test is uniquely sensitive to some underlying neurological damage, the improvement caused by repeated performance of that test is not trivial.No one would consider in significant an increase in the strength of an atrophied muscle as a result of an exercise regimen; this process would be called rehabilitation.Similarly, the improvement in performance resulting from practice on cognitive test uniquely sensitive to some underlying neurological damage should transfer to improved performance on other tests that seem based on a similar cognitive function.

In the early studies of experience dependent recovery (Forsberg and Goldman 1985), subjects practiced one version of a particular test and then were tested on another version of the same test to demon strate the transferability of their perform ance improvement.In more recent studies (Forsberg and Goldman 1987), practice on demanding visuospatial learning tests has resulted in performance improvements on a wide variety of other cognitive tests, but only if the tests were presented within the same sensory modality.For example, practice on some visually presented te ts resulted in improved performance on other visually presented tests but did not seem to improve performance on tests that de pended primarily on touch.Nevertheless, the broad transfer of performance improve ment suggests that providing practice for controlled, attentiondemanding cognitive tasks could enhance the impaired subjects' cognitive capabilities in other areas.In younger people, whose improvement could occur spontaneously over time, cognitive improvement seemed to be accelerated by practicing.In older alcoholic subjects, practicing helped increase their cognitive functioning, even on tests that would have revealed impairment for a much longer time if they had not practiced.Cognitive performance did not always improve to normal levels as a result of practicing, but it did improve significantly (Goldman 1987).

Other Strategies.Goldman and col leagues (1987;1990) investigated whether other experiencedependent strategies to induce recovery might be superior to simple repetitive practice.To this end, they broke a complex task into its component parts and trained subjects to perform these components so that the retraining process was easier and more accessible to people who might be frus trated by their cognitive dysfunction.Although su

ects recovered after this strategy
eyond what they would have with no training, the strategy was no better than simple practice.Apparently, alcoholics generally were not impaired to the extent that they required a more ele mental strategy than that of practice (as severely braindamaged subjects might).

A second strategy depended on prac ticing a task that was specifically de signed to require attention and effortful cognitive functioning.As seen in the first strategy, recovery using these techniques was approximately the same as recovery with simple practice on more traditional cognitive (neuropsychological) tests.This finding was consistent with the theory that a basic cognitive deficit in alcoholics is in the brain system(s) that control(s)

fortful processing and integration of multiple s
urces of information.


Implications of Cognitive Recovery

The general improvement seen in alcoholics' cognitive functioning after experience dependent recovery raises two fundamental questions with implications for successful treatment.First, does the cognitive im provement extend to behaviors that are directly associated with treatment (e.g., communication skills)?Second, can cogni tive rehabilitation strategies be used delib erately with alcoholics to improve their treatment outcome?The following section reviews the findings relating cognitive functioning to treatment outcome in gen eral.Unless impaired cognitive functioning prevents or retards effective treatment outcome, improved cognitive functioning would not affect how an alcoholic re sponds to treatment.


DOES COGNITIVE STATUS AFFECT TREATMENT OUTCOME?

As noted earlier, alcoholics' cognitive deficits most often are subtle.Whether deficits of this type have any relationship with treatment outcome is a question that must be answered with empirical research.To date, some research does indicate that cogn tive functioning (or dysfunctioning) relates to various aspects of treatment, including treatment outcome.For example, different studies have shown that less cogni tively impaired alcoholics are more likely to attend outpatient treatment, to complete a treatment program, to be rated by treatment personnel as having a better prognosis, and actually to have a better outcome.Other studies have found that cognitive measures predict how long after treatment a patient will resume drinking and the chances of a patient remaining abstinent for more than 6 months following treatment discharge.Alcoholics with better cognitive functioning are more likely to have fulltime employ me

and a higher monthly income at fol lowu
than are more cognitively impaired alcoholics (see Goldman 1990 for a review of specific studies).

On the other hand, some researchers have reported the relationship between cognitive deficits and treatment success to be modest at best or even inverse.They note that adding indicators of patients' cognitive status to statistical analyses does not increase the accuracy of the treatment outcome predictions that result from using only basic sociodemographic variables.Other researchers have urged caution before any adjustments are made to existing treatment programs that are based on what they consider to e an uncertain relationship (see Donovan et al. 1987, Goldman 1990, and Goldstein 1987 for more extensive discussions of the inconsistencies between these studies).


The Bases for the Inconsistent Findings

To understand why findings on cognitive impairment have been mixed, it is neces sary to appreciate that adequate cognitive functioning does not, by itself, ensure a better treatment outcome.It does provide a foundation on which other treatmentrelated factors may operate. 3The capacity to learn the kinds of skills and information that are taught by most treatment programs may be increased if the patient's thinking and learning mechanisms are intact.At least four factors may be responsible for the lack of consistent observations on the relation ship between cognitive functioning and treatment outcome.

First, the cognitive tests used in the studies described above are not necessar ily those est suited (most valid) for de tecting the aspects of dysfunction closely related to treatment outcome and general life functioning.These tests were origi nally selected because they were sensitive to brain damage caused by stroke, tumors, head injuries, neurological diseases, and other physical conditions and not because they could assess optimally the wide range of behaviors needed in daytoday living.Some neuropsychologists (Heaton and Pendelton 1981) suggest the need for tests that are similar to daily activities.For example, when a test based on knowl edge of familiar advertising used in maga zines was used to assess cognitive functioning in alcoholics, this test proved more statistically predictive of treatment outcome than did entire batteries of stan dard cognitive tests (Sussman et al. 1986).

Second, some research suggests that many current treatment modalities only minimally impact the factors influencing an alcoholic to drink.Therefore, it would not matter whether the cognitively im paired alcoholic could or could not learn the behavior taught by the treatment pro gram.If a method for teaching algebra is unclear and ineffective, both highly intelli gent and less intelligent children will fail to learn, reducing the observed relationship between intelligence and learning algebra.If alcoholism treatments are ineffective, reduced relationships between cognitive impairment and positive treatment out come may only reflect the ability of alco holics to recover on their own without the benefit of treatmentacquired coping strate gies.Treatments themselves must be im proved, and/or they must be matched to the functional cognitive level of the alcoholic before the true importance of differences in c

nitive funct
oning can be identified and evaluated.For xample, two recent reports on a patienttreatment matching study (Cooney et al. 1991;Kadden et al. 1989) provide somewhat unintended evidence for the importance of matching treatment complexity to patients' cognitive resources.Cognitively impaired patients did better in loosely structured interac tional group therapy than in highly struc tured behavioral coping skills training (the investigators originally had indicated that the structured training should offer an advantage for cognitively impaired alco holics).Perhaps this res lt is not so sur prising, however, when the large amount of information that must be acquired dur ing coping skills training is compared with the considerably lighter informational demands of interactional therapy.


Alcoholics'

cognitive deficits most often are subtle.

Third, in the first weeks and mont s after they stop drinking, alcoholics face a variety of environments, ranging from the very supportive to the very harsh.The more demanding the environment, the greater the recovering alcoholic's need will be for cognitive resources.The rela tionship between an alcoholic's cognitive status and treatment outcome will become clear only when the alcoholic experiences posttreatment events, such as finding and learning a new type of job, that will chal lenge the alcoholic's cognitive capacity.

Finally, cognitive functioning is only one among many influences that may affect treatment outcome.Motivation, the availability of social support networks, employment opportunities, comorbid psychiatric disorders, and numerous other factors also may play a role in how the alcoholic responds to treatment.

On the other hand, research r

orts may occasionally obscure the impact of cogni tive
deficits because the deficits interact with or overlap other treatmentrelated factors.For example, measures that predict treatment outcome-such as whether a person is able to perform an intellectually demanding job-contain components of cognitive ability.These predictors could be considered both ociodemographic factors and factors resulting from the extent of a person's cognitive impairment.Thus, the idea that cognitive impairment may not add to the predictive accuracy of sociode mographic factors on these outcomes does not mean that cognitive deficits have no effect on job performance.These appar ently different indices may be measuring the same thing, and the results from one set may mask the value of results from the other set.


THE IMPACT OF COGNITIVE DEFICITS ON TREATMENT OUTCOME

It is possible that even subtle cognitive deficits could affect how alcoholics seek and participate in treatment and resume normal lives in the weeks and months after they stop drinking.Three examples of different types of deficits and their impact on elements of treatment are pre sented below.

First, treatment professionals under stand "classic alcoholic denial" as a ki d of psychological avoidance or evasion of unpleasant reality.Part of this denial, however, may result instead from the alcoholic's limited ability to process the full range of available information about his or her drinking problem and a behav ioral inflexibility in making necessary changes in stopping the drinking.If denial is viewed as a part of the temporary brain damage caused by alcohol's toxic effects rather than as a refusal to accept responsi bility, different treatment approaches may be indicated for engaging the alcoholic in treatment other than the currently popular confrontational methods.These new approaches are more consistent with newer recommendations to avoid con frontational strategies and instead use strategies that increase motivation (Miller and Rollnick 1991).

Second, almost all treatment ap proaches depend, at some fundamental level, on interpersonal communication skills.Cognitive confusion may impede alcoholics' ability to effectively express their own thoughts and feelings as well as to clearly receive communications from treatment personnel.All aspects of treat ment may be affected by this difficulty.

Third, the essence of all treatment is the need for change-change in how one views the world and interacts with other people when not drinking and change in many routine habits.Unfortunately, the most frequent common denominator of cognitive impairment, including that which results from alcoholism, is the lessening of adaptability and flexibility.Even a quick review of Alcoholics Anonymous' (AA's) 12step philosophy reveals how much abstract thinking, concentration, and memory are required

absorb this material cognitively and apply it to maintaining a
ew lifestyle (e.g., recognizing that one is "powerless over alcohol," taking a "searching and fearless moral inventory," and listing "all persons...harmed"; AA World Services 1978).Similar cognitive demands arise in connection with most cognitive behav ioral treatments and in treatments that include learning information about how alcohol affects the body and the mind.Not only must the alcoholic make changes as part of treatment, but the new behav ioral repertoire learned also must be implemented in constantly varying daily situations.The alcoholic must be able to recognize a potentially problematic situa tion, resist old maladaptive responses, and implement new behaviors that may be far from thoroughly learned.


IMPROVING TREATMENT OUTCOMES BY FACILITATING COGNITIVE RECOVERY

As was demonstrated in the previous section, alcoholics may not benefit from certain aspects of treatment because of their cognitive deficits.As a result, alco holics with greater initial impairment would have a better chance of recovery from alcoholism if their cognitive im provement could be accelerated and brought to levels approaching normal be ore they entered treatment.In a recent study, Roehrich and Goldman (1993) found that they could use experience dependent recovery strategies to help accomplish these ends.The procedure essentially was the same as that used in earlier experiencedependent recovery research, with impaired alcoholics begin ning a sequence of repeated rehearsals of cognitive tasks shortly after they com pleted detoxification (figure 1).One significant change from prior studies was that the researchers gave the tasks to the participants in selfadministered work books, rather than being administered by assistants in a facetoface format.If cog nitive improvements could be observed in this format, the remediation procedure could be far less labor intensive and costly for actual clinical settings.

An even more critical change was that the alcoholic patients' ability to learn and implement a treatment component became a criterion for judging whether the alco holic had successfully benefited from the cognitive rehabilitation program.In their study, Roehrich and Goldman (19

) used relapse prevention training as the treat
ent component.They implemented this training in the latter phases of the cogni tive rehabilitation program.Four remedia tion strategies were compared, with a different group assigned to each interven tion.The str tegies included practice on standard cognitive (i.e., neuropsychologi cal) tasks, practice on ecologically rele vant tasks (figure 1), practice on placebo tasks (which required only automatic verbal responses), and no practice at all.Results showed that the remediation strategies that involved real tests were equally effective in helping alcoholics learn the relapse prevention material; they also were superior to both the placebo and no treatment groups.Longterm treatment outcome must await future research.


CONCLUSIONS AND FINAL TREATMENT RECOMMENDATIONS

Although the application of what is known about cognitive recovery to alco holism treatment is in its early stages, several recommendations can be made that then must be tested with appropriate research designs.

For example, many studies have demonstrated the profound cognitive deficits frequently seen in some alcoholics during withdrawal.Cognitive status, there fore, could be assessed routinely to guide treatment planning.For cognitively im paired alcoholics, the use of treatment components that demand heavy cognitive processing (these would include most current treatment methods) could be de layed until at least 1 to 2 weeks after the patients cease drinking.During this time, he treatment emphasis should be on assist ing the recovering alcoholic to avoid alco hol through a brief inpatient stay or by close monitoring on an outpatient basis by family members or friends (this approach is similar to some strategies used by tradi tional alcoholism treatment programs).After alcoholics have passed through this critical period, treatment components may be introduced in a systematic fashion, be ginning with the less cognitively demanding and progressing to the more demanding.Attent on to the therapy's cognitive de mands on the patient and to the cognitive needs of each patient (i.e., those required by the patient to cope in his or her environ ment) probably should continue well beyond traditional t